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What are your legal obligations to pay your doctor for treatment, above and beyond what your insurance will pay?

Related Topics: Insurance

Answers From Experts & Organizations (1)

Health Reform
924 Answers
1,289 Helpful Votes

"It depends on the doctor's relationship with the insurance company," says Richard E. Ungar, a Los Angeles-based health-care attorney. That relationship can make the difference between balance billing (not allowed) and billing you for a balance you owe (completely kosher).

Is Your Doc In Or Out?

A health-care provider who is in-network with your insurance company has negotiated a price for his or her medical services and signed a contract with your insurer agreeing to those rates as payment in-full. With the exception of your co-pay, deductible, or coinsurance, in-network providers generally cannot charge you more for their services. Doing so is considered balance billing, whether or not you've signed a form stating you'll pay the balance of what your insurer won't.

But that's not the end of the story. There are scenarios in which you may be required to pay beyond what your insurance company will, even if the doctor is in your carrier's network.

Duped by Details

There are details consumers commonly overlook about the rules of their insurance coverage that cause trouble, says Marty Rosen, executive vice president and co-founder of Health Advocate, a healthcare advocacy and assistance organization.

Forgetting the common requirement to pre-certify services before receiving care is a frequent mistake. Another is not confirming ahead of time whether you're being treated by doctors in your insurance carrier's network. "Failure to do so may result in denial of coverage by your insurance company and thus, large out-of-pocket fees," Rosen says.

Also watch for certain elements of a doctor's visit that your insurance coverage may not cover, Ungar warns.

For example, let's say you see an in-network doctor for a routine colonoscopy. Both the doctor visit and the procedure may be fully covered by your insurer. But if your doctor decides to use a newer sedative that requires an anesthesiologist to administer it (as opposed to doing it herself), Unger says, you could be on the hook for the anesthesiologist's charges.

In order to avoid unnecessary health care costs before you get care:

    * Make sure the service you need is covered.
    * Determine exactly what the contracted service includes.
    * Confirm that the doctor is in your network.

And don't sign any documents you don't understand or don't feel comfortable with.

This answer should not be considered medical advice...down arrowThis answer should not be considered medical advice and should not take the place of a doctor’s visit. Please see the bottom of the page for more information or visit our Terms and Conditions.up arrow

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